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psnet.ahrq.gov/web-mm/order-interrupted-text-multitasking-mishap
August 21, 2015 - include requirements to encrypt all data, to comply with specific password complexity settings, and to follow … Beam me up Scotty! Impact of personal wireless communication devices in the emergency department.
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psnet.ahrq.gov/node/865540/psn-pdf
April 11, 2024 - proactively requested the primary
provider to confirm NG tube placement on x-ray, there was no clear follow-up
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psnet.ahrq.gov/node/49684/psn-pdf
May 01, 2013 - and others)
often work in different areas of a hospital or clinic, deliver asynchronous care, and follow … ordering the wrong chemotherapy regimen.(16) Fortunately, an alert patient
had the courage to speak up
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psnet.ahrq.gov/node/851870/psn-pdf
July 31, 2023 - Staff wants to know that the care for the next patient is safer because they spoke up and
said something … While the intent is good, unfortunately they sometimes create conflicts that end up restricting the
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psnet.ahrq.gov/node/865411/psn-pdf
March 27, 2024 - is the leading cause of severe maternal
morbidity1 and preventable maternal deaths, accounting for up … had abnormal vital signs and multiple providers considered intra-abdominal hemorrhage yet no work-up
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psnet.ahrq.gov/node/74021/psn-pdf
October 25, 2021 - Sometimes verification requires picking up the phone and calling
the prescriber or patient. … Professional education in these instances is so important,
ensuring that you're up to speed with the
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psnet.ahrq.gov/web-mm/dose-makes-poison-medication-error-during-procedural-sedation-pediatric-emergency-department
January 23, 2017 - medical staff (nurses and physicians) were provided either prefilled medication syringes or allowed to follow … “I’m concerned”: a multi-site assessment of emergency medicine resident speaking up
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psnet.ahrq.gov/web-mm/comanagement-whos-charge
July 01, 2011 - The orthopedic resident assumed that the hospitalist was keeping up-to-date on developments and would … responsibility is disengagement of the surgeon.( 8 ) The presence of a hospitalist on the surgical wards frees up
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psnet.ahrq.gov/web-mm/hindsight-2020-thrombolytics-alcohol-intoxication
December 18, 2024 - examination, there was no facial droop, but facial symmetry was difficult to assess as he would not follow
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psnet.ahrq.gov/innovation/university-michigan-emergency-critical-care-center-ec3-provides-timely-intensive-care
October 30, 2024 - Study
Catching those who fall through the cracks: integrating a follow-up
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psnet.ahrq.gov/sites/default/files/2023-04/failure_to_ensure_patient_safety_leads_to_patient_falls_in_nursing_homes.pdf
January 01, 2023 - • Unfortunately, the patient could not follow instructions and did not
understand that she was unable … the use of full bed rails, if they were
present, they may have contributed to her ability to get to up
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psnet.ahrq.gov/sites/default/files/2023-09/a_missed_bowel_perforation_-_the_importance_of_diagnostic_reasoning.pdf
January 01, 2023 - Cultural and language barriers with patients
– Communication barriers between doctors
– Lack of back-up
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psnet.ahrq.gov/web-mm/failure-ensure-patient-safety-leads-patient-falls-nursing-homes
August 14, 2024 - Unfortunately, the patient could not follow instructions and did not understand that she was unable to … on the use of full bed rails, if they were present, they may have contributed to her ability to get up
-
psnet.ahrq.gov/node/50614/psn-pdf
October 30, 2019 - I didn't know this would fly as a research career, because the first question that came up was who
" … development award, I put together a group
of 15 experts from across the world (including a patient) to come up … In
this way, the most important principles are shared up front.
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psnet.ahrq.gov/perspective/conversation-carole-stockmeier-about-zero-harm-striving-reduce-preventable-harms-point
September 24, 2024 - And, when we do have an event of harm, the role of the leader is to help the organization pick itself up … notes that, since the 2013 launch of their Certified Zero Harm Awards, member hospitals have achieved up … Will health systems free up resources as harms become less frequent, or will efforts to reach zero harm
-
psnet.ahrq.gov/node/60241/psn-pdf
February 24, 2022 - results and should be considered in the context of the clinical
situation in that NH and may need follow-up … psnet.ahrq.gov//#68
Coronavirus Commission for Safety and Quality in NHs
As part of its “Opening Up … LTC facilities were able to sign up for the program and the CDC facilitated assigning
pharmacy partners … to each facility that signed up. … It is essential that NH
residents, staff, and visitors be vaccinated and up to date with CDC’s COVID
-
psnet.ahrq.gov/web-mm/failed-interpretation-screening-tool-delayed-treatment
August 20, 2018 - least two systemic inflammatory response syndrome (SIRS) criteria ( Table 1 ), yet SIRS criteria misses up
-
psnet.ahrq.gov/web-mm/duplicate-insulin-order
May 04, 2012 - Ensuring the ADC is set up to profile patient medications and that nonemergent medications are not available
-
psnet.ahrq.gov/web-mm/dangerous-shift
July 24, 2013 - and treatment plan (e.g., "Save the sick, do the others quick" strategy [ 16 ]) as well as speeding up
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psnet.ahrq.gov/web-mm/crossing-line
December 01, 2012 - The patient underwent an extensive work-up including bronchoscopy, which revealed a pyogenic lung abscess